Accurate Home Care

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on interview and document review, the agency failed to ensure visits were conducted as required in the plan of care and document the potential clinical impact of the missed service for 3 of 7 patients (P4, P10, P5) active records reviewed. Findings Include: P4’s plan of care (POC) for certification period 8/5/25 to 10/3/25, identified a start of care (SOC) date of 8/5/25. Principle diagnosis identified malignant neoplasm of tonsil unspecified (tonsil cancer). Services were ordered for skilled nurse (SN) visits two times per week times four, then one times a week times three. SN visits to provide patient education and instructions of enteral feedings, abuse prevention, fall precaution, home safety, and medication education. Physical therapy (PT) one time per week times one, then two times per week times four. PT visits to establish and teach home exercise program, fall prevention and endurance training. Home health aide (AIDE) one time per week times one, then two times per week times one. AIDE visits to assist with dressing, transfers, lotion and shower. Occupational therapy (OT) one time per week times one, then one times per week times six. OT visits for education, activities of daily living (ADL) training and therapeutic exercises. Review of P4’s visits completed during the recertification period 8/5/25 to 10/3/25, identified the following: -OT visit missed 8/6/25 -AIDE visit missed 8/8/25 -SN visit missed 8/14/25, 8/22/25, 8/29/25 P4’s medical record lacked documentation of education provided for potential clinical impacts for P4’s missed visits. P10 P10’s POC for certification period 9/12/25 to 11/10/25, identified a SOC date of 9/12/25. Principle diagnosis identified pulmonary fibrosis unspecified (lung disease that causes scarring and thickening of tissue making it harder to breath). Services were ordered for SN two times per week for two weeks, then one time a week times two weeks. SN visits to provide education on various medical conditions, medications, fall precautions, and home safety, OT one time per week times one week, then two times per week times two and then one time per week times two beginning on 9/22/25. OT visits to establish a home exercise program, home safety evaluation, teach fall and home safety, ADL training, transfers, activity tolerance and energy conservation. AIDE two times per week times four weeks. AIDE visits for assistance with personal care and ADLs. Review of P10’s visits completed during the recertification period 9/12/25 to 11/10/25, identified the following: -SN visit missed 9/19/25 -AIDE visit missed 9/17/25, 9/19/25 P10’s medical record lacked documentation of education provided for potential clinical impacts for P10’s missed visits. During interview on 9/24/25 at 8:23 a.m., director of home health (DOHH) indicated their agency’s usual process was to attempt to reschedule all missed visits and update the physician of missed visits. DOHH stated they were aware of the requirement to document a discussion with the patient of the potential clinical impact of missed visits and had discussed this at a recent interdisciplinary team (IDT) meeting. DOHH verified the missed visits for R4, R10 and R5 did not include this required documentation. DOHH stated it was important to discuss and document the potential clinical impact of missed visits for the patient’s understanding, as well as their health and wellbeing. The agency policy titled Home Health Staffing Policy revised 9/24/25, identified in the event of missed visit, every effort would be made to reschedule the visit within the same week. If a missed visit could not be rescheduled, the physician would be notified and the electronic medical record (EMR) would generate a corresponding order documenting the reason/circumstances, and the potential impact to the patient condition. The policy lacked instruction to discuss the potential impact of the missed visit with the patient. P5’s plan of care (POC) for certification period 8/28/25 to 10/26/25 included a start of care date of 8/28/25 and included diagnosis of fracture of the lower end of the right radius (wrist), fracture of one rib on the left side, and type 2 diabetes. Physical therapy was ordered for 2 times a week for 3 weeks, then 1 time a week for 3 weeks. P5’s EMR included a missed visit entry dated 9/5/25 with the reason included patient was not feeling well. Entry failed to include risk benefit education provided for missed visit. P5’s EMR included a missed visit entry dated 9/18/25 with the reason of patient was busy with other appointments for the rest of the week. Entry failed to include risk benefit education provided for missed visit.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on interview and document review, the agency failed to complete a comprehensive reconciliation of all medications at start of care (SOC) for 1 of 4 patients (P8) reviewed for medication reconciliation. P8’s plan of care (POC) for certification date 8/31/25 to 10/29/25, included a SOC date of 8/31/25. P8’s POC included diagnoses of type 2 diabetes, non-pressure chronic ulcer of left foot (a wound that takes an extended time to heal), and hypertension (high blood pressure). P8’s POC included the following medications: Atorvastatin 40 milligrams (mg) tablet Gabapentin 300 mg capsule Glimepiride 1 mg tablet Glucose 3.75 gram tablet Hydrochlorothiazide-lisinopril 12.5 mg – 20 mg tab Levothyroxine 0.5 mg tab Metformin 1000 mg tab Metoprolol tartrate 25 mg tablet Pantoprazole 40 mg tablet P8’s referral face sheet dated 8/29/25, included the follow medications: Amlodipine 5 mg tab Aspirin 81 mg chewable tablet Atorvastatin 40 milligrams (mg) tablet Gabapentin 300 mg capsule Glimepiride 1 mg tablet Glucose 3.75 gram tablet Hydrochlorothiazide-lisinopril 12.5 mg – 20 mg tab Levothyroxine 0.5 mg tab Metformin 1000 mg tab Metoprolol tartrate 25 mg tablet Pantoprazole 40 mg tablet During interview on 8/23/25 at 11:58 a.m., registered nurse (RN)-A confirmed she completed the SOC for P8. RN-A stated she reviewed the medications on the referral document, however did not compare them the medication bottles or discuss the medications with the assisted living facility P8 lived in because it was the weekend and nursing staff was unavailable. RN-A stated the assisted living facility managed P8’s medications, so she assumed they had the correct orders from P8’s primary care provider. During interview on 9/24/25 at 8:37 a.m., director of nursing (DON) confirmed a thorough medication reconciliation should be completed at all SOC visits. The DON stated this should be completed by reviewing the medication bottles against the referral orders and clarify any discrepancies with the provider. The DON stated even if the patient has an assisted living facility managing their medications, the medication reconciliation should have been completed with whatever staff was available on the day of SOC. Facility provided policy for medication management dated 2019, included a registered nurse would complete a comprehensive medication regimen review every 60 days.”

“Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on observation, interview and document review, the agency failed to ensure an up to date medication list was in the home for 1 of 4 patients (P5) reviewed during home visits. Findings include: P5’s plan of care (POC) for certification period 8/28/25 to 10/26/25 included a start of care date of 8/28/25 and included diagnosis of fracture of the lower end of the right radius (wrist), fracture of one rib on the left side, and type 2 diabetes. Intervention for skilled nurse included to prefill medication planner device weekly on Tuesdays. During home visit on 9/23/25 at 12:30 p.m., P5 and P5’s daughter in law (FM)-B confirmed the nurses from the agency set up medications for P5. FM-B stated she was unsure exactly what medications were set up and was not sure where a current medication list for P5 was. During interview on 9/24/25 at 8:18 a.m., licensed practical nurse (LPN)-A stated all patients should have a current medication list in the home. LPN-A stated a medication list should have been mailed by office staff and it should be changed with each medication change. During interview on 9/24/25 at 8:44 a.m., director of nursing (DON) confirmed every patient should have an up-to-date medication list in the home. DON confirmed this was important so the patient and visiting staff would be aware of what the patient was taking. Facility policy for medication management failed to include instructions on a medication list.”

“Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA’s internal policies. (4) When services are provided on the basis of a physician or allowed practitioner’s verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA’s policies, must document the orders in the patient’s clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA’s internal policies. This Element is not met as evidenced by: Based on observation, interview and document review, the agency failed to document in writing the verbal orders received by the physician for 1 of 3 patients (P1) reviewed for nursing services. P1 had a start of care (SOC) date of 9/5/23. P1’s plan of care (POC) dated 11/6/23 to 1/4/24, signed by the provider revealed diagnoses including congenital malformation syndromes predominantly affecting facial appearance, congenital malformations of trachea, dependence on respirator (ventilator) status, chronic respiratory failure with hypoxia, diseases of upper respiratory tract and acute tracheitis without obstruction. P1’s POC indicated approval for 20 hours per day of complex RN/LPN, flex use per patient and family needs and shared with All About Caring Home Care. During an interview with licensed practical nurse (LPN-A) on 12/19/23, LPN-A indicated she had used a hand pummel to assist with bronchial drainage (BD) due to P1’s increased secretions and need for more frequent suctioning. LPN-A indicated she participated in a televisit conference with Children’s Respiratory and Critical Care (CRCC) physician, CRCC home coordinator nurse and family member-A (FM-A). During this televisit the physician verbally indicated it would be OK to implement bronchial drainage (BD) with a palm cup as needed but did not feel P1 would be appropriate for a bronchial drainage vest due to lack of muscle/head control. Review of P1’s current POC, did not indicate BD’s as needed and no written verbal order noted in medical record. P1’s nursing documentation, entered 10/9/23 by LPN-A, indicated the virtual visit and physician not recommending the pummel vest due to muscle tone and head strength but did not note the approval for intervention of palm cup for BD’s. The nursing documentation did indicate the pulmonology nurse would fax over the color code sheet for steps to take for respiratory illness. Review of P1’s medical record did not indicate the color code sheet was faxed to agency nor followed up on. During a home visit to P1 on 12/19/23 2:40 p.m., FM-A removed the color-coded sheet titled Respiratory Control Plan from the bulletin board above the supply dresser in P1’s room to show surveyor, in addition, FM-A provided a bag of 4 palm cups that she thought LPN-A had brought into the home as she had no clue how they came to be. During a telephone interview with CRCC patient care coordinator (PCC) on 12/20/23, the PCC verified there were orders for manual BD’s with palm cup and indicated the order was sent to Pediatric Health Services to send the palm cups out to the home but no indication the order/televisit was ever sent to the agency. During an interview on 12/20/23 12 p.m. the director of clinical services verified there were no orders for manual BD’s with palm cup in P1’s medical record or on the POC. She also indicated they did not receive the respiratory control plan or televisit notes from CRCC until requested by surveyors. The respiratory control plan, dated 10/9/23, was signed by the pulmonologist with the BD orders printed on it (observed the color copy in P1’s home 12/19/23). The director of clinical services would expect the nurse to write a verbal order at the time she received the “OK” to do BD’s as needed or have the case manager complete the verbal orders. The director of clinical services provided immediate re-education to all nurses via e-mail 12/20/23. Policy titled Medications and Orders Policy, Created: 2015, Revised: 2019, directs 1. Verbal orders are only accepted by personnel authorized to do so by applicable state and federal regulations. 2. f. A copy of the order must be communicated to the registered nurse in charge and recorded or placed in the patient’s record.”